Issues in Developing Programs for Uninsured Children: A Resource Book for States

By The Lewin Group

ForThe Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy, U.S. Department of Health and Human Services

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Introduction

A. Purpose of the Resource Book

This resource book has been developed for states planning to implement new or expand existing children's health insurance programs in response to the availability of funding provided under Title XXI of the Social Security Act. The resource book contains reference information on nine states that established children's health insurance expansions prior to enactment of Title XXI. It is intended to provide relevant information for states as they design their own children's health insurance programs. The experiences of the state programs documented in this resource book have been identified as a result of a project funded by The U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy. The project focused on existing state children's health insurance programs in nine states: California, Colorado, Florida, Massachusetts, Minnesota, New York, Pennsylvania, Tennessee, and Washington.

The resource book includes information on the nine programs, the benefits offered, cost sharing arrangements, eligibility criteria and enrollment processes, outreach efforts, provider issues, and coordination with other types of programs. Examples of state programs and approaches are provided, however, they are not intended to be an identification or description of best practices.

B. The Enactment of Title XXI of the Social Security Act and States' Need for Information

Enabled under Title XXI of the Social Security Act, the State Children’s Health Insurance Program (CHIP) is providing $24 billion in funding to states over a five-year period to provide health insurance to uninsured children. The purpose of the law is to assist states in initiating and expanding children’s health assistance programs to uninsured, low-income children. The primary objective of Title XXI, to expand coverage for uninsured children, allows states to expand coverage beyond current Medicaid eligibility limits. This assistance can be provided through one of three methods: (a) a program to initiate and expand the provision of health care assistance via a separate State Insurance Program; (b) a Medicaid expansion; or (c) a combination of these methods. Coverage includes children under age 19 not eligible for Medicaid with family incomes below 200% of the federal poverty level or 50% above the current state Medicaid limit. State expansions could begin as early as October 1, 1997. Each state is eligible to receive a portion of the total amount, and allotments remain available for up to three years.

As a result of the enactment of Title XXI, states are faced with the challenge of designing and implementing programs that will increase the enrollment of eligible children without encouraging the substitution of employer-sponsored insurance. The complexity of family decisions, state policy objectives, and program design may impact the ability of a program to meet its intended goals. For example, states must consider the complexity of family dynamics as decisions to enroll in health insurance programs are based on the affordability of plans, the comprehensiveness of benefit packages, and the health status of their children, among other factors. Likewise, decisions regarding how and to what extent to expand coverage for uninsured children will be made in the context of broader state policy objectives and existing state programs. Existing and potential policies regarding insurance reform, efforts to assist employers in providing coverage, potential substitution of private coverage, and state social and economic policies are likely to be examined in the broader context of planning for expanded children's coverage. Additionally, the overall design of a state program will impact its ability to conduct outreach and enroll eligible children. The experiences presented in this resource book provide information and an historical context for states developing programs under Title XXI.

C. Methodology

Information provided in this resource book is based on information collected from program representatives of the nine study states. The criteria used to select the programs included: type of program (e.g., Medicaid expansion, state-sponsored, or foundation-sponsored), geographic location, age and size of program, and scope of the program. State representatives, including program directors, Maternal and Child Health directors, and Medicaid staff from all nine states were interviewed on their experiences in designing and implementing children's health insurance programs. Information collected through the interview process has been organized in a database created for the purpose of collecting children’s health insurance program, administrative, and legislative information.

D. Structure of the Resource Book

This resource book is specifically focused on six issue areas. As many children's health insurance programs have been in existence for only a short period of time, a number of these issues have only recently been identified and have not yet been fully evaluated. In general, there is little data to reflect best practices and overall efficacy of programs.

This resource book has been organized into issue areas related to the design and structure of children's health insurance programs. There may be some overlap across selected areas discussed in this resource book as some of the issues and state activities are closely related. Each chapter provides the following: an overview of the issue; a brief description of the approach the study states has taken within their program; and tables that exemplify or summarize the efforts of each state program.

• Section I discusses issues related to eligibility and recertification; Section II outlines the enrollment processes for each of the nine states; Section III focuses on the outreach and marketing efforts of the state programs; Section IV provides a description of issues related to the provider networks employed by state programs; Section V describes the role and collection of premiums and copayments; Section VI explains the coordination of children's health insurance programs with other programs and services;
• Appendix A provides an overview of the nine state children's health insurance programs;
• Appendix B lists the nine state programs, their administrators, and contact names and addresses; and
• Appendix C includes outreach and marketing materials and enrollment forms from the selected states.

E. Programs Included in this Review

The following programs are included in this Resource Book.

STATE	PROGRAM
California	CaliforniaKids
Colorado	Children’s Health Plan
Florida	Health Kids Corporation
Massachusetts	Children’s Medical Security Plan
Minnesota	MinnesotaCare
New York	Child Health Plus
Pennsylvania	Children’s Health Insurance Program
Tennessee	TennCare
Washington	Washington Basic Health Plus

I. Eligibility Criteria and the Verification Process

A. Overview

Over the past several years, states have approached the issue of children’s health insurance in many different ways and for a variety of reasons based on the needs of target populations and the basic premise upon which programs were established. Consequently, current eligibility standards and verification processes utilized by children’s health insurance programs differ widely across states.

Some states, such as Minnesota and Tennessee, have chosen to expand coverage for children as part of a larger statewide Medicaid expansion. The use of Medicaid waivers to extend eligibility has allowed many states to reach beyond the scope of "children's-only" initiatives in order to cover families and single adults as well. Eligibility guidelines for these state programs usually expand current Medicaid eligibility requirements, and the processing of applications is often done within the same agency.

Other states have chosen to establish separate children’s health insurance programs independent of the current Medicaid system. Establishing a separate program provides states with added flexibility to design eligibility requirements and a system for program administration.

• Eligibility for subsidized coverage through the Florida Healthy Kids program is determined by eligibility guidelines already established by the National School Lunch Program. In order to verify eligibility and administer the program, Florida has established the Healthy Kids Corporation, a program separate from Medicaid and other public assistance programs. In contrast, Pennsylvania established their Children’s Health Insurance Program (CHIP) within the Department of Insurance. However, the insurance plans contracting with CHIP, rather than state CHIP staff, are responsible for verifying the eligibility of applicants. The CaliforniaKids program exists as a private organization and therefore, its eligibility requirements are not subject to the same federal and/or state regulations.

This section examines states' approaches to the various aspects of developing and implementing eligibility and verification processes.

B. Eligibility Requirements

For each of the nine states examined, a core group of eligibility criteria were identified: age, family income, residency status, and access to health insurance. Table 1 exhibits basic eligibility criteria for the nine selected states.

1. Age

Age was initially identified as an important eligibility requirement, particularly for states establishing programs independent of Medicaid. The determination of the target population (i.e., the decision to serve children only versus all uninsured residents of the state) is a decision central to the structure of the program and consequently influences future program decisions. Several states suggested that as children are relatively inexpensive to insure, funds may be more effectively utilized by providing coverage for and services to younger children first, and then to consider establishing or expanding a program to insure more costly adults. States must also consider the cohort of children which they plan to insure, as this may impact total enrollment and, therefore, the scope and breadth of services to be provided by the program. States opting to implement Medicaid expansions have determined age eligibility by either utilizing or expanding the current standards.

Most states that have developed separate programs have established unique age eligibility standards.

• Programs in Colorado, Pennsylvania and New York initially limited eligibility to children under age 13.
• Due to low enrollment, budget surpluses and new funding, eight of the nine states now cover children up the age 18.
• The remaining state, Colorado, will be expanding coverage up to age 18 starting in July, 1998, when the current Colorado Children’s Health Plan (CCHP) is replaced by the new Children’s Basic Health Plan (CBHP).

2. Income

Income eligibility requirements are much more diverse across the nine state programs, ranging from 185% of poverty to no income limitations. State programs that have established income eligibility at higher income ranges have established cost sharing arrangements in which enrollees contribute to the cost of their insurance through premiums and copayments.

• MinnesotaCare, TennCare and New York’s Child Health Plus program determine premium contributions on a sliding scale based on total family income.
• Colorado Children's Health Plan extends eligibility to 185% FPL and requires an annual flat enrollment fee of $25 for all children enrolled in the program, regardless of family income.

3. Residency

States often institute residency requirements in order to prevent migration of uninsured persons from neighboring states. Programs employing residency requirements will usually require enrollees to be a resident of the state for some specified minimum period.

• MinnesotaCare requires enrollees to have established residency for a minimum of six months before becoming eligible for MinnesotaCare. This applies only to adults without children. The Medicaid criteria apply to families with children.
• Other states use residency requirements to prevent (or allow) illegal immigrant children to access their state program.
• Washington requires applicants to reside in the state and have United States citizenship.
• The CaliforniaKids program requires applicants to reside within the state, but it does not require enrollees to have already established legal residency in the United States.

4. Access to Coverage

Another common factor used to determine eligibility is the ability of an applicant to access other types of health insurance coverage (e.g., private/employer-based coverage, Medicaid, etc.). States that have established children's health insurance programs separate from Medicaid often require enrollees to be ineligible for Medicaid before being enrolled into their program. This requirement has been established to maximize the number of uninsured children a state can cover in their program while referring Medicaid-eligible children to the state Medicaid program. Nevertheless, the procedures needed to do this may be administratively burdensome especially if they find very few Medicaid-eligible children. For example, a study conducted by the state of Florida showed that only 0.42% of Florida Healthy Kids' enrollees were actually eligible for the state Medicaid program. Florida does not require Medicaid ineligibility, but Healthy Kids does prevent children currently enrolled in Medicaid from concurrently enrolling by cross-referencing each applicant in the current Medicaid beneficiary database.

Although states may have the ability to cross reference their applicants with a current Medicaid beneficiary list, it is difficult for states to clearly identify enrollees' ability to access private insurance. The intention of this restriction is to prevent families from dropping existing private coverage in order to enroll in a state-subsidized program, an effect identified by states as "substitution". Some states, such as Minnesota, have responded to the issue of substitution by requiring a period of uninsurance, a minimum amount of time in which a person has no access to insurance, before they are eligible to enroll in the state program.

5. Periods of Uninsurance

Periods of uninsurance can sometimes create barriers to enrolling individuals in need of coverage. For example, this type of restriction may prohibit individuals who have access to, but cannot afford the private insurance for them and their dependents. A similar situation may arise when private insurance benefit packages offered to employees and their dependents are limited and do not cover many essential services. Such concerns have prompted states to allow for exceptions to current uninsurance requirements.

• In Pennsylvania, if a family is able to document that copayments and/or premiums make it difficult to afford existing private insurance coverage, CHIP will waive the period of uninsurance requirement.
• MinnesotaCare has addressed this issue by defining "employer-based coverage" as private insurance coverage in which an employer contributes at least fifty percent or more to the cost of coverage. MinnesotaCare has also exempted children in families below 150% of poverty from periods of uninsurance when a benefit package offered under private coverage is less comprehensive than the package offered under the state's Medicaid program.

States interviewed suggested that it is difficult to verify and enforce limitations on coverage and periods of uninsurance among applicants. This has resulted in states dropping or modifying such provisions within their programs.

• Florida's Healthy Kids initially required families to have no access to private insurance for six months prior to becoming eligible for the program. As it was difficult for the program to verify applicants' access to coverage, Florida eliminated this requirement.
• The Washington Basic Health Plan had difficulty enforcing a requirement that permitted enrollees to have access to private insurance only if it was less comprehensive than that offered by BHP. As a result of the administrative burden involved with defining and verifying "less comprehensive" coverage, the Basic Health Plan dropped this provision.

Table 1: Basic Eligibility Criteria for Children

State and Program	Age	Income	Residency Requirements
CaliforniaKids	2-18	100-200% FPL	Must live in California but legal residency is not required. If school age, must be enrolled and attending school.
Colorado Children’s Health Plan (CCHP)	<13	<185% FPL	Must reside in Colorado and be a U.S. citizen or a documented immigrant.*
Florida Healthy Kids	5-19	No Income Limits	Florida relies on the school district to screen for residency. Healthy Kids is offered to any child enrolled in the school district.
Massachusetts Children’s Medical Security Plan (CMSP)	<19	No Income Limits
MinnesotaCare	<21	<275% FPL	Must be a permanent resident of Minnesota.
New York Child Health Plus	1-19	<222% FPL	Must live in New York but legal residency is not required.
Pennsylvania Children’s Health Insurance Program (CHIP)	<16	<185% FPL 0-6 years: 185-235% FPL	Must reside in Pennsylvania for at least 30 days. Must be a U.S. citizen or legal immigrant.
Tennessee TennCare	<18	No Income Limits	Must reside in Tennessee and be a legal U.S. resident, but proof of legal U.S. residency is not required by application.
Washington Basic Health Plus	0-19	<200% FPL	Must be a legal resident of Washington.

*The Colorado Child Health Plan also allows the children of migrant workers to enter the program if they meet three criteria: first, the child's parents must maintain a residence in Colorado for at least part of the year; second, the child must meet U.S. citizenship criteria; and third, one member of the child's family must be employed in Colorado.

Table 2: Eligibility Limitations Based on Access to Other State Programs

Program	Medicaid Ineligibility Required	Access to Program Limited Based on Availability of Private Insurance	Period of Prior Uninsurance Required
CaliforniaKids	Yes.	Access to private insurance prohibited. (Exceptions occasionally made for families with high co-pays or deductibles.)	None.
Colorado Children’s Health Plan (CCHP)	Yes.	No restriction. CCHP actively encourages families to also carry private insurance so that everyone in the family has health insurance.*	None.**
Florida Healthy Kids	No. Children do not need to be ineligible for Medicaid, however they may not be enrolled in both Medicaid and Healthy Kids at the same time.	No restriction.	None.
Massachusetts Children’s Medical Security Plan (CMSP)	Yes.	Access to private insurance prohibited. (Exception made for families with only catastrophic coverage.)
MinnesotaCare	N/A. MinnesotaCare was created as a Medicaid expansion.	Must not have access to employer–paid insurance (50% or more) for 18 months. Children in families under 150%FPL can enroll if the benefit package offered by their private insurance plan is less rich than the benefit package offered through Medicaid.	Must be uninsured for previous 4 months.
New York Child Health Plus	Yes.	No restriction based on access to private insurance, although a child may not be currently enrolled in other equivalent private insurance.	None.
Pennsylvania's Children’s Health Insurance Program (CHIP)	Yes.	Access to private insurance prohibited. (Exceptions occasionally made for families with high co-pays or deductibles.)	None.
TennCare	N/A. TennCare was created as a Medicaid expansion.	There is no uninsurance requirement for children. Access to private insurance prohibited for adults. TennCare mails a form to all employers each year asking them to specify whether or not their employees are offered insurance. This information is used to verify eligibility for TennCare.	None.
Washington Basic Health Plus	N/A. Basic Health Plus was created as a Medicaid expansion.	There is no uninsurance requirement for children.	None.

*Due to Title XXI restrictions, the new Colorado Basic Health Plan will require that families be without access to employer-based coverage (where the employer pays fifty percent or more of the cost) for a minimum of three months before becoming eligible for the program.
**The new Children's Basic Health Plan will require that a child be without employer-based coverage for the prior three months. Employer-based coverage is defined as health insurance coverage where the employer paid for 50% or more of the cost.

C. Eligibility Verification Process

The complexity of state eligibility verification processes is dependent upon the number of verification requirements and the resources available to program staff. Of the nine study states, seven had administrative staff employed by the program (or the state agency) to process enrollment and verify eligibility. New York and Pennsylvania were the two exceptions. Both New York and Pennsylvania require the health plans with which they contract to collect applications and determine the eligibility of applicants. Enrollment processing time is variable across states and programs. The time of application to actual program enrollment ranged from one day in Massachusetts and Tennessee to four months in Pennsylvania. The wait time in Minnesota is typically 30 days for processing and an additional 30 days, pending awaiting payment of the premium. There have been delays from time-to-time when program expansions create an influx of new applicants. Pennsylvania noted that the processing of an application requires approximately one month; however, as a result of their current waiting list, there may be a three to four month delay before coverage begins.

Some states utilized presumptive eligibility as a strategy to reduce the waiting time between the point of application and enrollment into the program. With presumptive eligibility, children are assumed eligible for a specific period of time until the documentation of their eligibility can be verified. Once complete, children are either officially enrolled or disenrolled in the program, depending on eligibility status. Currently, both Massachusetts' Children’s Medical Security Plan and New York's Child Health Plus Program use presumptive eligibility.

Table 3: Verification Methods

Program	Verification Responsibility	Presumptive Eligibility	Average Time From Initial Application To Enrollment
CaliforniaKids	Program Staff verify eligibility of applicants.	No presumptive eligibility.	Processing time is 2-6 weeks.
Colorado Children’s Health Plan (CCHP)	Program Staff verify eligibility of applicants. Colorado also contracted with a foundation to help process applications.	Yes-Children are considered "eligible" on the date that the application form is mailed to CCHP. "Presumptive eligibility" lasts until verification is complete and the child is placed into an HMO. During the time of presumptive eligibility, the child’s care is paid by CCHP on a fee-for-service basis.	Processing time is 15-45 days.
Florida Healthy Kids	Program Staff verify eligibility of applicants. School district and Medicaid Department provide enrollment databases for their programs to facilitate process.	No-This has been considered, but there is not strong support from the public due to the chance that ineligible children would start to be subsidized by local funds.	Processing time is 4-6 weeks. Enrollment begins the first of the month after verification.
Children’s Medical Security Plan (CMSP)	Program Staff verify eligibility of applicants.	Yes- Children can be presumptively enrolled for up to 45 days while family eligibility is verified.	It takes approximately one week for enrollment to begin for families who mail in the application form. Coverage begins immediately for children who apply by phone due to presumptive eligibility rules.
Massachusetts Children’s Medical Security Plan (CMSP)	Program Staff verify eligibility of applicants.	Yes- Children can be presumptively enrolled for up to 45 days while family eligibility is verified.	It takes approximately one week for enrollment to begin for families who mail in the application form. Coverage begins immediately for children who apply by phone due to presumptive eligibility rules.
MinnesotaCare	Program Staff verify eligibility of applicants for both MinnesotaCare and Medicaid.	No presumptive eligibility.	It takes approximately 30 days to process the application. Families then must pre-pay for their first month’s coverage. Enrollment starts the first day of the following month. It usually takes 2-3 months from when the application is submitted until enrollment begins.
New York Child Health Plus	Participating HMOs verify eligibility of applicants.	Yes-Children can be presumptively enrolled for up to 60 days while family eligibility is verified.	Enrollment under presumptive eligibility begins as soon as the application is received and is made permanent when the necessary documentation is submitted. The child is dropped from CHP if the family does not submit the necessary documentation by the end of the 60 day presumptive eligibility period.
Pennsylvania Children’s Health Insurance Program (CHIP)	Participating HMOs verify eligibility of applicants.	No presumptive eligibility.	It takes approximately 1-2 months to process the application. Usually an additional 3-4 months on the waiting list before enrollment begins.
TennCare	Program Staff verify eligibility of applicants.	No presumptive eligibility for children. Pregnant women are allowed 45 days of presumptive eligibility.	Applicants make an appointment with the county health department and are told what documentation to bring when they come. Appointments take about 15 minutes. Benefits for qualified applicants begin that day.
Washington Basic Health Plus	The Department of Social and Health Services (DSHS) does the eligibility verification of applicants and enrollment for both Basic Health Plan and Basic Health Plus. The list of eligible names are then forwarded to both agencies.	No presumptive eligibility.	On average, it takes between 5-6 weeks for a child to be enrolled in Basic Health Plus. Families must enroll by a specific date the month before coverage begins, so it can sometimes take longer if children apply at the end of the month.

D. Length of Enrollment and Recertification

One of the most significant challenges faced by children’s health insurance programs, particularly the stand-alone programs, is the creation of a "seamless" system. Insurance status of some children fluctuates as family income and coverage change within a given year. Such children may be eligible for a separate state insurance program one month, covered under private insurance the next, and eligible for Medicaid in the following month. This fragmentation of coverage and the discontinuity of care that may result is an important issue policy makers have grappled with over the past year. Changes in insurance status for children has become a major barrier to accessing appropriate care. First, families may not realize that once they become ineligible for one program that they have become eligible for another. Second, the provider networks that provide care within one program may not have an arrangement to provide care under the other. This becomes problematic when families must seek care from new physicians under different plans on a regular basis. As a result, many children in publicly funded programs have decreased access to and a lack of continuity with health care services.

Several state programs have attempted to create a "seamless" system of care for children focused on those children in situations with rapidly changing family income.

• The Colorado Children’s Health Plan is considering continuous eligibility for their program in which children enrolled in the program are enrolled for one full year, regardless of their Medicaid eligibility status throughout that year. Colorado plans to establish continuous eligibility under their Title XXI plan, but they have not determined the method by which they will track income and eligibility changes throughout the enrollment period. The process will most likely require the Colorado Medicaid program to provide a monthly report identifying current Medicaid beneficiaries. CCHP will then cross-reference this list with the list of their enrollees. If a child enrolled in CCHP is found to be enrolled in Medicaid, CCHP will discontinue the capitated payment to the CCHP physician for the period in which the child is enrolled in Medicaid. If the child then becomes ineligible for Medicaid and returns to CCHP, payment to that child's physician will be reinstated.

It is important to examine the issue of continuous enrollment and recertification as the eligibility status of a substantial number of children will inevitably fluctuate: families move to different states, incomes rise and fall, employment status changes, and children begin to "age out" of state-sponsored programs. Most of the nine children’s health insurance programs presented require enrollees to be recertified on an annual basis. Of the states examined, annual turnover rates have been identified to be as high as 40%. This is an important finding, and may be due to some extent to the difficulty some families have in dealing with the enrollment process.

Several states are attempting to create simple enrollment processes in order to prevent children in need of coverage from dropping out of the system.

• Florida automatically recertifies children enrolled in Healthy Kids unless they are notified by the parent of a change in insurance status (e.g., private insurance or public assistance).
• CaliforniaKids distributes a renewal form to all parents two months prior to the deadline for recertification.

Table 4:
Continuous Eligibility and the Recertification Process

State and Program	Continuous Enrollment	Frequency of Recertification
CaliforniaKids	Children are continuously enrolled for 12 months.	Recertification is required every 12 months. CaliforniaKids sends a letter two months prior to the deadline to remind parents.
Colorado Children’s Health Plan (CCHP)	Children are continuously enrolled for 12 months. CCHP receives monthly report from Medicaid. If they see that a child has enrolled, they simply discontinue the capitation for that month and resume it again if the child goes off Medicaid.	Recertification is required every 12 months. CCHP sends a letter to the parents a few weeks prior to the deadline to remind parents.
Florida Healthy Kids	Children are continuously enrolled for 12 months.	N/A- Children are automatically re-enrolled in Healthy Kids every year. Parents are sent a letter reminding them of the program.
Massachusetts Children’s Medical Security Plan (CMSP)	Children are continuously enrolled for 12 months.	Unicare sends out letters on an annual basis to verify income.
MinnesotaCare	Children are continuously enrolled for 12 months.	Recertification is required every 12 months. As long as family continues to pay the premium, income has not changed, and they have not acquired other insurance, they are re-enrolled.
New York Child Health Plus	Children are continuously enrolled for 12 months.	Recertification is required every 12 months.
Pennsylvania Children’s Health Insurance Program (CHIP)	Children are continuously enrolled for 12 months. If a child goes on Medicaid during this period, CHIP continues to hold a spot for them in the program and coordinates with Medicaid to make sure that child can keep their current CHIP provider.	Recertification is required every 12 months. Families need to resubmit proof of income.
TennCare	Children are continuously enrolled in TennCare for an indefinite period of time.	Currently recertification is not required. TennCare is in the process of developing an annual recertification process, but this has not yet been implemented.
Washington Basic Health Plus	Children are continuously enrolled for twelve months. Famililes would only lose eligibility on a voluntary basis if they choose to report an income change that makes them ineligible for the program.	The Washington Department of Social and Health Services makes eligibility and enrollment decisions for Basic Health Plus. Not every individual is recertified due to limited resources. DSHS has established criteria to determine who will be recertified on an annual basis according to their date of birth.

II. the Enrollment Process

Families with uninsured children access health care through various means. Some families apply for state- or federally-subsidized health insurance, i.e., Medicaid, while others rely on direct health care programs for their care such as community health centers and WIC. One of the biggest challenges states are facing is the creation of an enrollment system focused on channeling uninsured children into the most appropriate program without losing them in the process. To address this concern, states are beginning to channel uninsured children into appropriate programs by creating more coordinated enrollment processes among Medicaid, separate state insurance programs, and other existing state programs (e.g., Title V and welfare programs). None of the nine states opted to use enrollment brokers.

The following sections present strategies used by the nine study states to establish a seamless enrollment process.

A. Coordination with Medicaid

Seven out of the nine children’s health insurance programs we examined receive referrals from their state Medicaid program, and all but one also refer Medicaid-eligible children to their state's Medicaid program.

• In some instances, referral into the most appropriate programs is an informal process.
• In Pennsylvania, children who have applied for CHIP and have been deemed Medicaid-eligible are notified (in written form) of their ineligibility for CHIP and are instructed to apply for Medicaid. In Philadelphia, there is also a 1-800 number, operated by the Pennsylvania Department of Health in cooperation with two local consumer groups, that "screens" callers to determine if they are eligible for Medicaid or for CHIP. Callers who appear to qualify are sent a simplified one-page application form. Those appearing to be eligible for Medicaid are referred to help lines where counselors take applications and explain procedures. No formal process is in place to ensure the enrollment of these children into Medicaid.
• MinnesotaCare is establishing a coordinated enrollment process, going into effect in 2000, using the same employees to process applications for Medicaid and for MinnesotaCare. These employees will be trained to place applicants in the most appropriate program.

1. Spend-down Requirements

The "spend-down" process is another dynamic that has resulted in an interaction between children’s health insurance programs and Medicaid. "Spend-down" refers to the process in which a family must spend its income on health care services until its resources are reduced to a level in which they become eligible for Medicaid. Spend-down is most often seen in the case of children with special health care needs who may require expensive inpatient care. Some children’s insurance programs, particularly those separate from Medicaid, often require families to spend-down and become Medicaid eligible.

• The Pennsylvania CHIP program has a medically needy provision that directs children requiring inpatient care to spend-down. The spend-down process in Pennsylvania is most often initiated by the hospital on the first day the child is admitted. The hospital will provide the child’s family with a Medicaid application and an estimate of the expenses the child will incur during hospitalization. Within ninety days, the state's Medicaid program will recalculate the family’s Medicaid eligibility, and will take begin to pay the child's medical expenses from that point. During this period, CHIP coordinates with Medicaid to allow the child to remain with the CHIP physician, rather than requiring the child to switch to a new provider. If a child's health status improves and/or the income of the child's family rises and the child is no longer eligible for Medicaid, CHIP will permit the child to re-enter the program.

2. Barriers to Coordination

A common difficulty in coordinating enrollment between Medicaid and other children’s health insurance programs is the incompatibility of computer systems and technology. Often state Medicaid programs will have a different enrollment system than the insurance program, prohibiting the two programs from screening applicants simultaneously or tracking the changing income levels of children.

• Colorado is addressing this issue in the design of the Children’s Basic Health Plan (CBHP) by creating a system of ID numbers and family information that will be compatible with the system currently used by the Medicaid program. The state believes that this type of system will prevent the "fall out" of children eligible for one program or the other.

In addition to computer systems and technology not being compatible between the two programs, the application process for Medicaid tends to be more complex than enrollment procedures for a separate children’s health insurance program. Families are often deterred from enrolling in Medicaid due to complex application procedures and requirements for face-to-face interviews. In contrast, many state children’s health insurance programs have much simpler application procedures.

• The application for the Colorado Children's Health Plan can be completed through the mail and is approximately four pages long if the child is not enrolled in any other state-subsidized programs. If the child is enrolled in another state program (e.g., WIC, Free and Reduced Price Meal Program), the family is only required to complete a one page enrollment form. However, the Colorado Medicaid application is twenty-five pages long and requires a face-to-face interview.

Table 5: Program Coordination with Medicaid

State and Program	Referral of Applicants by Medicaid to the Children's Health Program	Medicaid-Eligible Applicants Referred by the Children's Health Program?	Requirement of Spend-down into Medicaid
CaliforniaKids	No-Medicaid does not currently refer to the program.	Yes-If an applicant is eligible for Medicaid, they are given information about who to contact for an application.	N/A-Current program covers only preventive and primary health care and does not include inpatient coverage. Children requiring inpatient care are usually referred to the Medi-Cal program on an individual case-by-case basis.
Colorado Children’s Health Plan (CCHP)	Yes.	Yes-If applicant is eligible for Medicaid, their $25 application fee is returned with a letter advising them to apply for Medicaid at the county Department of Social Services.	N/A-Current program covers only preventive and primary health care and does not include inpatient coverage. Children requiring inpatient care are usually referred to the Colorado Indigent Care Pool (CICP).
Florida Healthy Kids	No. This is something they are looking into for the future.	No- A study showed that only 0.42% of Healthy Kids enrollees were actually eligible for Medicaid. Healthy Kids decided that this did not justify the administrative cost of screening for Medicaid eligibility.	No.
Massachusetts Children’s Medical Security Plan (CMSP)	Yes-When a child is denied eligibility for Mass Health (Medicaid) they are sent an application for CMSP.	Yes-If a child applies to CMSP but is eligible for Mass Health, they are enrolled in CMSP under presumptive eligibility and given an application to apply for Medicaid. The Medicaid office is also notified and the family is included in outreach efforts.	Yes-A one-time spend-down process exists whereby an individual has a six month window to achieve spend-down in order to be eligible for a Medicaid benefit package.
MinnesotaCare	Yes-By year 2000.	Yes- Families who are eligible for both Medicaid and MinnesotaCare are given the choice between programs. The benefits packages are the same, but some families prefer to pay the premiums required by MinnesotaCare in order to avoid the "welfare" stigma associated with Medicaid.	No.
New York Child Health Plus	Yes-The New York Department of Social Services (DSS) refers children to the program and helps with the transition when children go off Child Health Plus and onto the Medicaid program.	Yes-Child Health Plus advises county DSS offices regarding referrals of Child Health Plus applicants who are Medicaid eligible.	No- Families are not required to participate in spend-down, although they are encouraged to apply for Medicaid if their family income situation changes and it appears that they might be eligible.
Pennsylvania Children’s Health Insurance Program (CHIP)	Yes-Medicaid applicants who are determined ineligible are automatically sent a CHIP application. The county Medicaid offices usually coordinate with the CHIP HMO operating in the region to facilitate this process.	Yes- CHIP plans are required to refer ineligible children to Medicaid.	Yes-Families are required to participate in spend-down whenever a child requires inpatient hospitalization. However, CHIP also gives these children priority re-entrance into CHIP when their health status improves and they once again become ineligible for Medicaid.

B. Coordination with Other State Programs and Private Providers

States have found the coordination among children’s health insurance programs and other social service and health programs to be more difficult. Programs in which uninsured children commonly access health services (i.e., WIC, Head Start, and community health centers) are often administered by an office other than Medicaid or the state children’s health insurance program. Other children access health care through private physicians or hospital emergency rooms. These variable points of access to the system have made it difficult for states to identify eligible children. Most of the children’s health insurance programs examined in this report suggested that other social service agencies in their state were fairly consistent in educating families about insurance programs and distributing applications. However, few states had established a formal referral process to ensure the application of children into the appropriate program through some type of follow-up provision.

• The Florida Healthy Kids program has approached the issue of locating eligible children by basing the program enrollment process in the public schools. Brochures and applications are distributed to all children in school throughout all of the counties participating in the Healthy Kids program. Children enrolled in school and eligible for the National School Lunch Program (children in families with an income below 185%FPL) are automatically eligible for the program with a full or partial subsidy. In addition, all children enrolled in school are permitted to enter the program; however, the amount of subsidy (based on a sliding scale from 0-100%) is dependent upon family income. To facilitate the verification process, the school districts provide Healthy Kids with a database containing information regarding school enrollment and participation in the National School Lunch Program.
• Colorado has worked to establish a more formal linkage between enrollment in CCHP and other state social service programs by developing a brief enrollment form for families currently eligible for any one of six other state programs. Programs include: WIC, the Health Care Plan, the state prenatal program, the Colorado Indigent Care Pool and three additional food assistance programs. CCHP relies on the staff of these other programs to verify the eligibility, income and assets of the child’s family. The enrollment staff of CCHP then processes the short application and enrolls eligible children into the program. CCHP is in the process of developing an internet-based enrollment system that will provide clinics, private providers and other social service staff with the ability to process the enrollment over the computer.
• Massachusetts has coordinated with hospitals in the state to refer potentially eligible children to the Children’s Medical Security Plan because emergency rooms were identified as a common place for uninsured children to seek primary health care services. As a result, children arriving at emergency rooms for health care are screened for insurance status. Children without insurance are then referred to CMSP.

Table 6:
Enrollment Coordination with Other State Programs and Private Providers Table

State and Program	Potential Applicants Referred by Other State Programs?	Common Enrollment Form Used in Conjunction with Other State Programs?	Applicants Can Be Enrolled by Private Providers?
CaliforniaKids	Yes. Program partners with school nurses, Head Start, Healthy Start and AIM programs.	No.	No. All applications must be processed by CaliforniaKids.
Colorado Children’s Health Plan (CCHP)	Yes. Children enrolled in HCP, WIC, the state prenatal program or one of three food programs can be automatically enrolled in CCHP.	Yes. Short enrollment form developed to screen families for eligibility into CCHP, HCP, WIC, Colorado Indigent Care Pool, and three food programs.	No. However, Colorado is exploring the potential implementation of an internet-based enrollment system as part of the new Children’s Basic Health Plan. This would allow private physicians and hospitals to actually process CBHP applications over the computer.
Florida Healthy Kids	Yes. Healthy Kids has had an informal arrangement with Florida’s MCH programs to coordinate care for children who require more extensive health care services. Healthy Kids is currently trying to formalize this process.	No.	No.
Children’s Medical Security Plan (CMSP)	Yes. WIC and school health nurses are trained to target uninsured children and refer them to program.	No.	When children come to the emergency room for care, they are asked if they have insurance. If not, they are referred to CMSP.
Massachusetts Children’s Medical Security Plan (CMSP)	Yes. WIC and school health nurses are trained to target unisured children and refer them to program.	No.	No.
MinnesotaCare	Yes. County health departments make referrals to MinnesotaCare on an informal basis.	No.	No.
New York Child Health Plus	Yes. Other state programs refer to program on an informal basis.	No.	No. Private providers distribute information with the names and numbers of the CHP plans in the child’s area. The family is responsible for contacting the plans for an application.
Pennsylvania Children’s Health Insurance Program (CHIP)	Yes. Department of Health screens for CHIP eligibility through its toll-free Healthy Babies hotline. BC/BS Caring Programs also make referrals to CHIP.	No.	No.
Tennessee TennCare	Yes. The state MCH Department is very active in making referrals to TennCare. All county clinic nurses attend a training class on TennCare.	No.	No.
Washington Basic Health Plus	Yes. The Washington Basic Health Plan refers eligible children to the Basic Health Plus Program. (About 40% of their applicants are referred this way.) WIC program also refers families.	Yes. Children and their parents enroll into the Basic Health Plan and Basic Health Plus (Medicaid program for children) with the same application form.	No.

III. Collection of Premiums and Copayments

A. Overview

States need to consider a number of complex issues as they design cost-sharing requirements for children's health insurance programs. Cost-sharing mechanisms are seen in both public and private programs and are implemented for the following reasons: 1) to reduce the costs associated with providing care; 2) to deter the inappropriate utilization of services (e.g., use of the emergency room for primary health care); 3) to instill a sense of responsibility in participants for their health care; 4) to minimize the welfare stigma associated with public programs; and 5) to prevent the substitution of private insurance. The majority of the study states established cost-sharing requirements in order to instill in their enrollees a sense of responsibility and ownership and to reduce the welfare stigma often associated with public programs.

1. Price Sensitivity

It is important to recognize the importance of price sensitivity among families when establishing levels for premiums and copayments. "Price sensitivity" refers to the level of premiums and copayments that families perceive to be affordable. It is important to note that price sensitivity may not always be what families can afford, but rather what they are willing to pay for health care services. States’ consideration of cost-sharing levels is critical to assuring the success of a children’s health insurance program, as it influences the families' incentives to enroll in a program and utilize services.

2. Type of Cost Sharing to be Implemented

Related to the issue of price sensitivity is the decision whether to implement either a flat fee or a sliding scale premium. While a flat-fee may be administratively appealing, designing a sliding scale premium based on family income may encourage participation. Of the states examined, the Colorado Children’s Health Plan is the only program utilizing a flat enrollment fee. The other eight states have established monthly premiums based on a sliding scale. The Florida Healthy Kids program has a sliding scale based on the three levels of the National School Lunch Program (Free Lunch, Reduced Lunch, and Not on Lunch Program). The seven remaining states have sliding scales based specifically on income.

This section details the strategies used by the nine study states to collect premiums and copayments and the penalties for families that do not pay their monthly premiums.

Table 7: Cost-Sharing Requirements of the Nine State Plans

	CaliforniaKids	Colorado Children's Basic Health Plan	Florida Healthy Kids	MA Children's Medical Security Plan	MinnesotaCare	New York Child Health Plus	Pennsylvania CHIP	TennCare	Washington Basic Health Plus
Monthly Premiums			x	x	x	x	x	x
Annual Enrollment Fee		x
Copayments	x	x	x	x		x	x		x
Family Cap

B. Procedures for Collecting Premiums

Six of the nine children's insurance programs examined in this report collect monthly premiums: Florida, Massachusetts, Minnesota, New York, Pennsylvania, and Tennessee. Each of these programs determines premium levels based on a sliding scale. The premium sliding scales for these six states are shown below in Tables 8 through 13. These programs collect and process payments through a central office.

• The Florida Healthy Kids Program requires parents to mail monthly premiums to the program office.

• In Minnesota, monthly premiums must be either sent by mail or paid in person at the state MinnesotaCare office. Minnesota is currently investigating other options to permit parents to pay premiums by automatic payroll and checking withdrawal, assigning tax returns, and/or credit card payments.

In addition to these six programs, the Colorado Children's Health Plan currently collects a $25 annual enrollment fee due at the point of application. Pennsylvania, does not collect premiums, but rather requires the contracted health plans to collect premiums.

Table 8: Florida Healthy Kids Corporation Premium Sliding Scale^*

County	VOLUSIA	DADE	SANTA ROSA	HARDEE
Free Lunch	$10	$10	$5	$5
Reduced Lunch	$25	$20	$15	$13
Not on Lunch Program	$48	$51	$53	$49

*A sliding scale of costs is developed by each local project and submitted to Healthy Kids for approval. A family's eligibility for the National School Lunch Program confirms eligibility for a reduced premium. This table shows examples of premium sliding scales for four local projects.

Table 9: Massachusetts Children’s Medical Security Plan Premium Sliding Scale

Monthly Premium	$0	$10.50 per child up to family maximum of $31.50	Full premium $52.50 per child
Percentage of Poverty	0-200%	201-400%	+400%

Table 10: MinnesotaCare Premium Sliding Scale*

Percent of Poverty	Premium Contribution by Number Covered
	1	2	3
0-62%	$4	$8	$12
62-89%	$5-7	$10-14	$15-21
89-115%	$9-12	$18-23	$28-35
115-142%	$16-19	$32-39	$48-58
142-168%	$24-28	$49-57	$73-85
168-195%	$36-41	$73-83	$109-124
195-221%	$52-58	$103-116	$155-174
221-248%	$74-82	$147-163	$221-245
248-275%	$98-128	$196-255	$294-383

*MinnesotaCare enrollees pay a monthly premium based on family size and income. This table consolidates a more extensive premium sliding scale for a family of fourso that it may be compared to others based on the %FPL. The full premium is $128 per person per month.

Table 11: New York Child Health Plus Premium Sliding Scale

Monthly Premium	$0	$9 per child up to family maximum of $36	$13 per child up to family maximum of $52	Full premium: $58-99 per member *
Percentage of Poverty	0-120%	120-159%	160-222%	+222%

*The full premium for NY Child Health Plus depends on the insurance company and the location. For example, insurance companies in NY City have the highest premiums.

Table 12: Pennsylvania CHIP Premium Sliding Scale*

GRANTEE AND REGION	FREE	SUBSIDIZED	STATE SHARE SUBSIDIZED
Central CBC/KHPC CBC/KHPC KHPC & USHC	$63.00 $46.44 $52.23	$81.90 $60.37 $67.90	$40.95 $30.19 $33.95
Northeast BCNEPA First Priority Health	$59.14 $59.14	$76.88 $76.88	$38.44 $38.44
Southeast USHC & KHPE	$52.23	$67.90	$33.95
Western KHPW USHC & KHPW BCWPA	$64.25 $51.77 $62.50	$83.53 $67.30 $81.25	$41.77 $33.65 $40.63

*Chart from CHIP annual Report for contract year July 1, 1995 through June 30, 1996. CHIP pays 50% of the subsidized rates. BCNEPA-Blue Cross Northeast PA (Caring Foundation of Northeastern PA). BCWPA-Blue Cross Western PA (Western PA Caring Foundation). CBC-Capital Blue Cross (Caring Foundation of Central PA). First Priority Health-Caring Foundation of Northeastern PA. KHPC-Keystone Health Plan Central (Caring Foundation of Central PA). KHPE-Ketystone Health Plan East (Independence Blue Cross & PA Blue Shield). KHPW-Keystone Health Plan West (Western PA Caring Foundation). USHC-U.S. Healthcare.

Table 13: TennCare Premium Sliding Scale

Family Monthly Premium	$0	$24.50	$32.25	$47.50	$70.50	$183.50	$200.75
Percentage of Poverty	0-100%	101-119%	120-139%	140-169%	170-199%	200-209%	210-219%

C. Procedures for Collecting Copayments

Seven of the nine children's insurance programs collect copayments: California, Colorado, Florida, Massachusetts, New York, Pennsylvania, and Washington. All seven programs require contracted providers (i.e., physician's offices, hospitals, pharmacies) to administer the collection of copayments. In Colorado, however, providers are not required to collect copayments specified for services rendered, yet in order to promote patients' responsibility for their health care, they are encouraged to do so.

Table 14: Co-Payment Levels for the Nine State Plans

	CaliforniaKids	Colorado Children's Basic Health Plan	Florida Healthy Kids	MA Children's Medical Security Plan*	MinnesotaCare	New York Child Health Plus	Pennsylvania CHIP	TennCare	Washington Basic Health Plus
Office Visits	$5	$2	$3	$1-5	No copayments for children.	$2		No copayments.	No copayments.
Health Screenings		$2		$1-5		$2
Outpatient Surgery							$5
Outpatient Mental Health			$5				$5
Emergency Room	$25		$25				$5
Ambulance Transport
Hospital Admission
Vision Care	$10
Eyeglasses			$10				$5
Hearing Screenings and Aids							$5
Prescriptions		$2	$3				$5
Non-generic prescriptions	$10	$2
Dental	$10						$5

*Massachusetts has sliding scale copayments based on family income guidelines of $1, $3, or $5.

D. Issues Related to the Non-payment of Premiums

States have established various policies related to the non-payment of required monthly premiums. For example, states that have required premiums have identified the length of time they will permit children to remain in the program when their parents neglect to pay monthly premiums or annual enrollment fees. Three of the six states with monthly mail-in premiums distribute at least one warning letter before disenrolling a child. In other programs, the lack of payment for services rendered (30, 60 days) will result in the disenrollment from the program.

• The Colorado Child Health Plan requires families to renew enrollment on an annual basis. If enrollees fail to pay the annual enrollment fee, they are disenrolled from the program. CCHP distributed a survey in 1996 to identify the reasons that children were not re-enrolled into the program. Of the 42.6% of children enrolled in CCHP who did not renew their coverage, 23% were too old to qualify; 29% moved out of the area; 11.5% became Medicaid eligible; 11.5% had increased family assets and were no longer eligible for CCHP; and 14% acquired other insurance.

• In the Florida Healthy Kids Program, families are required to pay monthly premiums one month in advance. For example, the premium for the month of December is due November first. Families who fail to submit the premium by the 7^th of the month receive a late fee notice, reminding the enrollee of the premium payment and warning that coverage may be cancelled if the payment is not received. If the payment is not received by the 14^th-17^th of the month, enrollees will receive a second warning letter. On the 28^th of the month, a cancellation letter is sent out to inform the family that their child's coverage has been cancelled. In recognition of the difficulty of some families to make payment, there is a liberal reinstatement policy.

• In Minnesota, beneficiaries are provided a 30 day grace period and if they fail to pay one monthly premium are disenrolled from the program and are not eligible to reenroll for another four months. "Good cause" exceptions to 4 month penalties can be made. At this point, Minnesota does not conduct any follow-up with families to identify reasons for missed premium payments. Minnesota program officials are currently examining their policy to identify its effectiveness. In New York, families are provided a thirty-day grace period if they fail to pay their child's monthly premium. During this time they are sent a reminder letter regarding the monthly premium. However, if payment is not made by the end of the thirty-day grace period, the beneficiary is dropped from the program.

• In Pennsylvania, health plans contracted by CHIP have the option of terminating the child’s coverage if families miss their monthly premium; however, individual plans have the freedom to decide when and how to cancel coverage. The Department of Insurance has no formal regulations concerning the non-payment of premiums by families enrolled in CHIP, and all decisions are determined by the contracted plans.

• In Tennessee, if a premium is not received, a warning notice is issued indicating that enrollment will be terminated within sixty days if payment is not received. After the first 30 days, families are sent a notice that enrollment will be terminated within 30 days. After the entire sixty day period is up, if families have not yet made payment they are disenrolled from TennCare. However, if families pay the back premiums, they can be reinstated at any time.

IV. Outreach and Marketing

A. Overview

The success of children’s health insurance programs hinges on the program’s ability to enroll the eligible children. States’ experiences demonstrate that while some portion of the eligible population is generally easy to reach, there are others who are considered "hard to reach." In particular, the "hard to reach" populations present specific challenges for outreach and marketing efforts that may need to be specifically targeted, non-traditional, and often community-based in terms of enrollment strategies. These children and their families face many barriers in obtaining health insurance coverage including:

• confusing eligibility rules and complex application procedures;
• cultural and language problems;
• isolation of the target population from local and state health departments;
• transportation problems; and
• perception of welfare stigma often associated with state programs.

As states implement new programs under Title XXI, the issue of how best to reach uninsured children will be critical to the programs’ success. In particular, the 3.4 million children who are eligible for Medicaid but not enrolled may present major challenges to states in conducting effective outreach to uninsured children. States must explore these barriers and develop appropriate strategies to enroll eligibles. In order to reach the eligible population, successful outreach and marketing campaigns need to be continuous, widespread, multiform, have varied sources of information and be geared to a specific population [Williams, S., (December 8, 1997). Child Health Gains May Hinge on Aggressive Outreach. Medicine and Health Perspectives. 51(47), 1-4.]. For example, TennCare targets the African-American community in Shelby County by having local religious leaders educate their congregations about the program.

This section presents strategies that are currently being used by the nine study states to enroll eligible, uninsured children: successful strategies; outreach and marketing methods; preparation of marketing materials; coordination with other programs; and budgets. Samples of marketing/promotional materials are presented in Appendix C.

B. Successful Strategies

1. Understanding the Target Population

Outreach begins with understanding the target population, communicating the availability of health care coverage, and educating potential beneficiaries about the program eligibility requirements and how to sign up. States have implemented a variety of approaches and some states have used multidimensional outreach campaigns that combine printed materials, radio and television advertisements. Programs often distribute brochures at schools, churches, hospitals, clinics, businesses, government agencies, and other community sites.

School-based enrollment strategies have been implemented in Colorado, Florida, Massachusetts, and Tennessee (See Table 15).

• Colorado considers the "back to school enrollment program" their best outreach vehicle. The Child Health Plan operates under the philosophy that people may need to be exposed to the program three times before they react. Hence, the back to school program attempts to outreach to potential enrollees three times in close succession via television, radio, and written advertisements. In 1996, over 210,000 pamphlets were distributed to 848 Colorado schools in 42 counties.
• All Florida school children receive a uniform Healthy Kids brochure introducing them to the program, and Healthy Kids posters are displayed in schools.These materials stress the importance of scheduling regular preventive physician visits while enhancing recognition of the Healthy Kids program.
• In Massachusetts, informational letters are sent home with approximately 200,000 school children in 120 school districts. This effort has been successful in particularly for enrolling adolescents in the Children’s Medical Security Plan.
• In Tennessee, a consumer group assists the TennCare program with their outreach efforts. Fliers are distributed to every school and day care center in the state in order for children to take them home to their parents. This has proven to be an inexpensive and effective form of marketing for TennCare.

Table 15: Outreach and Marketing Methods

	Written Materials	Toll-Free Hotlines	Language Facilitation	Television	Radio	Word-of- Mouth	Community Meetings	Posters
CaliforniaKids	x		x			x
Colorado Child Health Plan	x	x	x	x	x		x	x
Florida Healthy Kids	x	x	x					x
Massachusetts Children’s Medical Security Plan	x
MinnesotaCare	x	x	x	x	x	x		x
New York Child Health Plus	x			x		x	x
Pennsylvania CHIP		x
TennCare	x				x		x
Washington Basic Health Plus	x			x	x	x	x

2. Use of Multilingual Materials

Many states have translated promotional materials into the languages of their target populations.

• Both Colorado and California offer outreach literature in English and Spanish.
• In Florida, special emphasis is placed on recruiting staff with multi-lingual talents. Staff are available who speak Spanish, Creole, Dutch, Danish, German, Arabic, Greek and English. Applications are printed in Spanish, Creole, and English.

Another approach to overcoming language and literacy barriers is staffing the hotlines with bilingual workers.

• Spanish speakers are available to assist Colorado residents in filling out applications for the Children’s Basic Health Plan through a toll-free phone line.

3. Word-of-Mouth

Studies in both Minnesota and New York found that most enrollees generally learned about the programs by word-of-mouth.

• In New York, most parents of enrolled children heard about Child Health Plus from a friend, school, or their doctor. Very few individuals have been reached as a direct result of a specific marketing activities such as TV, mailings, or community meetings. New York stresses that outreach and marketing continues to be a very important issue for their program. Even with the current marketing efforts of Child Health Plus, New York has only a 30% rate of penetration into their targeted population.

4. Impact of Geographic Differences on Marketing Efforts

Colorado’s Child Health Plan found that individuals from diverse geographic regions reacted differently to varied marketing strategies. When the Child Health Plan initially marketed the program within the Northeast region of the state, it was presented as a private insurance plan with a cost of $25 per year. The hope was that by making the state program comparable to private insurance, it would prevent individuals from linking the program with welfare. However, the effort was unsuccessful in enrolling children within this region of the state because residents were not trusting of the program. In the Western region of the state, however, county resource centers, public health departments, schools, and other community groups were supportive of the program. These Western counties created a system in which those individuals rejected from Medicaid would receive an application for the Colorado Child Health Plan. This coordinated strategy was very effective in Colorado.

5. Mass Marketing versus Local Marketing

Though most of the states rely on mass marketing techniques to educate the public about their programs, Colorado, Tennessee and Washington target individuals at the local level to promote the program.

• In Colorado, five CCHP staff members work very closely with communities and conduct local outreach training. The state staff also created a database of county public and social service agencies that work with low-income families with children. The database helps state outreach workers coordinate efforts with local groups.
• Tennessee state officials conducted outreach meetings in all ninety-five counties, where they presented a video on TennCare that explained the program’s purpose and eligibility qualifications. Applications were distributed after the presentation. TennCare also employs this approach to outreach in town meetings, churches, and other community events. TennCare also uses local health departments as enrollment sites to engender community support.

• The Washington Basic Health Plus program targets individuals at the local level by training staff at community organizations and clinics about the program and enrollment procedures.

C. Coordination With Other Programs for Outreach and Identification of Potential Enrollees

1. Coordination

Five of the nine state programs described extensive efforts to coordinate with other children's programs and agencies for outreach and the identification of potential enrollees. States detailed the advantages of being able to capitalize on other organizations' expertise in attracting enrollees to their program.

The existing networks of community health organizations and schools are logical areas for children's health insurance programs to market their programs.

• CaliforniaKids partners with community organizations to identify and enroll eligible children. The organization's partners include: school nurses, Head Start and Healthy Start programs, Child Care Councils, Child Health, Disability and Prevention Program (CHDP), Access for Infants and Mothers (AIM), Boys and Girls Club, and Big Brothers, Big Sisters.
• In Florida, county public health departments and providers distribute applications for Healthy Kids. In addition, child care programs also market Healthy Kids by distributing pamphlets and applications.
• In Florida, county public health departments and providers distribute applications for Healthy Kids. In addition, child care programs also market Healthy Kids by distributing pamphlets and applications.

In many instances, existing organizations and administrative systems can be utilized to target the most needy children.

• Florida uses the school lunch program as a mechanism for charging reduced premiums to families. All children are eligible for the program, so the school lunch program serves as an administratively simple way for Healthy Kids to determine family need and identify the most appropriate subsidy level. This process for verifying children requires schools to send Healthy Kids an electronic table of all enrolled students and their eligibility for free and reduced lunches.
• In Massachusetts, the Children's Medical Security Plan coordinates with schools to send informational letters home with children. This coordination has been successful, especially in enrolling adolescents. In addition, WIC, MCH, family planning and community health clinics distribute informational materials on CMSP at their sites. Infants and toddlers are often reached through nurses, MCH programs, and the area hospitals (e.g., when children enter the emergency rooms for care, parents are questioned regarding their insurance status, and when applicable, they are referred to CMSP). CMSP coordinates closely with Medicaid, WIC, primary care sites, and the school health programs. For example, CMSP conducts joint marketing and outreach activities with Healthy Start to target families eligible for both programs. As CMSP has expanded its focus to include adolescents, the program has also worked closely with family planning clinics, state immunization programs and substance abuse programs.

Children's health insurance programs can capitalize on existing administrative skills and marketing knowledge of state agencies.

• The Massachusetts Children's Medical Security Plan (CMSP) was moved from the Department of Insurance to the Department of Health to capitalize on the marketing and outreach experience of the Medicaid and Maternal and Child Health Departments. It was understood that the Department of Health would target all children not eligible for Mass Health (Medicaid) and undocumented children, and that the use of this outstanding relationship between MCH and Medicaid would assist with the success of CMSP. After the move of the program to the Department of Health, enrollment increased from 20,000 to 36,000 children due to outreach and coordination efforts with other programs.
• In Minnesota, there has been a mixed effort to coordinate with other agencies to enroll potential beneficiaries. When MinnesotaCare was operated as a separate program focused on children, many state agencies referred children to the program. However, as the program has expanded to include all uninsured, outreach needs have increased substantially. It has been more difficult to keep up with those needs without more resources. Minnesota has embarked on a major outreach effort including a $1.5 million legislative appropriation to 26 separate grantees throughout the state, to reach targeted populations. Because enrollees transition in and out of eligibility for MinnesotaCare, a significant amount of time is devoted to coordinating with other public agencies. Minnesota has identified training new program staff about Medicaid as well as training Medicaid staff about MinnesotaCare to be essential in their outreach efforts. Minnesota has also developed a combined application form in which a potential enrollee can indicate an interest in being considered for both Medicaid and MinnesotaCare. Although the application is a combined effort, the eligibility determination continues to take place in two separate offices until the year 2000, when county agencies will have the option to administer MinnesotaCare.

One area of concern in reaching eligible children is reaching those with special health care needs.

• Minnesota Children with Special Needs, Minnesota’s Title V program for children with special health care needs, has a long history of working closely with both Minnesota’s Medicaid and MinnesotaCare programs to assure that children with chronic illnesses or disabilities have access to a comprehensive array of services. To facilitate this process, MCSHN has a toll free number that is designed to answer a variety of questions from referral resources, providers, and families of children with special health care needs. Minnesota continues to struggle with the implementation of a one-stop-shopping model for children with special health care needs. However, progress has been made with a single application for families to access Medicaid, MinnesotaCare, or MCSHN services. Joint use of eligibility cards and payment systems has also reduced confusion for providers for families. Efforts continue to move to a more seamless system of eligibility and services for children with special health care needs and their families.

D. Preparation of Materials

1. In-House Marketing Efforts

The majority of the states interviewed prepare outreach and marketing materials in-house. Florida and Washington have staff who are responsible for marketing and outreach in addition to other program responsibilities. Other programs have staffs who do not have outreach or marketing as part of their job title, yet are responsible for conducting these activities as part of their general responsibilities.

• Of the 13 people employed by Florida Healthy Kids, one employee is solely dedicated to outreach and marketing functions. Another individual is responsible for assisting with outreach, and is also responsible for the preparation of enrollment forms.
• Initially, Washington Basic Health Plus designated specific staff members to be "outreach workers." However, Washington no longer actively recruits individuals into their program and does not require staff to perform marketing, communication, and outreach duties in addition to their other responsibilities. In order to enroll, families must contact the Washington Health Care Authority.

2. Use of Contractors

In contrast to Florida and Washington, Massachusetts and New York have employed contractors to market their programs.

• The Massachusetts’ Children’s Medical Security Plan is redesigning promotional materials with John Hancock Insurance Company to include program eligibility changes. An informational flyer will be used to specifically target teens and their families.
• In New York, outreach and marketing materials are prepared by three different sources: Child Health Plus staff, contracted insurance plans, and marketing contractors. Specific state staff act as liaisons to the marketing departments of the contracted plans and marketing contractors. Two groups were contracted: one designated specifically for New York City; and the other the rest of the state. Both engaged in major activities including targeting schools and health centers, producing large volumes of mailings, and organizing meetings and presentations to over 16,000 individuals. Any materials developed outside of Child Health Plus must be submitted and approved by the state office. There are also specific clauses in contracts with plans and contractors to prohibit them from using fraudulent marketing and enrollment activities.
• In the Pennsylvania CHIP program, The State Department of Insurance is not involved in marketing. In contrast to other programs, contracted providers are required to produce and distribute their own outreach and marketing materials.
• TennCare’s managed care organizations conduct their own marketing. Marketing guidelines are provided to the contracted managed care organizations in addition to the marketing rules specified in their contracts with TennCare. TennCare reserves the right to approve all marketing materials before distribution.

Table 16: Coordination with Partners

	Schools	Child Care Centers	Health Dept.	Providers	Local Partners	State Partners	Other
California	x	x		x	Child Care Councils; Boys and Girls Club; Big Brothers/ Big Sisters; Healthy Start	Child Health, Disability, and Prevention Program (CHDP); Head Start; AIM
Colorado*	x		x		County resource centers	WIC; prenatal and nutrition programs; Colorado Indigent Care Program; HCP (children with special health care needs);
Florida	x	x	x	x
Massachusetts	x			x	Family planning clinics; community leaders; area hospitals, nurses; Healthy Start	School Health Unit in State Dept. of Public Health; immunization programs; substance abuse programs; Maternal and Child Health Dept., WIC, Medicaid	John Hancock
Minnesota	x		x	x	County resource centers, local media, ethnic outreach organizations, city help centers, migrant services, neighborhood health care networks, children’s home care organizations.		$1.5 million in grants over the biennium to groups interested in developing outreach efforts in their communities
New York						State Dept. of Social Services; Medicaid; Welfare; WIC; Prenatal Care Assistance Program (PCAP)	Marketing contractors
Pennsylvania						Department of Health; Medicaid;	Contracting HMO’s do their own marketing
Tennessee			x			WIC; other state officials	Contracting MCO’s do their own marketing; TennCare Consumer Advocacy Group; Tennessee Medical Association; Pediatric Associations
Washington					5 Staff from BHP went into the community	WIC	Health service alliance contractor; insurance agents and brokers earn commissions by selling Basic Health.

*Because Colorado Children's Basic Health Plan has not yet been implemented, outreach and marketing information comes from the state-sponsored Colorado Child Health Plan's experience (CCHP). The current CCHP will roll into the new Children's Basic Health Plan.

E.Outreach and Marketing Budgets

Most programs rely upon public information campaigns via media and large population techniques rather than on community outreach workers who may interact directly with the targeted population. In the nine states, the percentages of program budgets allocated for outreach and marketing ranged from 1% to 16%.

• Washington allocates less than 1% of their administrative budget for marketing, comprising approximately 7.5% of the total premium budget. For all materials produced, funding is drawn exclusively from the printing and postage budget. At the onset of the program, approximately 2% to 5% of the administrative budget was spent on marketing. However, this amount has been reduced as they are no longer actively recruiting beneficiaries. Since most outreach and marketing is conducted through community stakeholders, the administrative allocation for marketing and outreach has never been substantial.
• In Florida, total administrative costs for marketing and outreach are 5.2% of the total budget. This includes administration and evaluation in addition to outreach and marketing. As marketing is primarily targeted within schools, costs include the production of the enrollment forms, flyers for children to take home, and posters to display in schools.
• New York provides approximately 1% to 2% of their total budget for outreach and marketing efforts.
• In Pennsylvania, the contracted insurance plans for the Pennsylvania CHIP program are required to spend 2.5% of their grant allocation on outreach and marketing. Most plans actually conduct substantial amounts of outreach and marketing based on in-kind contributions.
• Colorado and California also place a high emphasis on marketing and outreach and have allotted approximately 11.3% and 16% of their total program budgets for this purpose.

1. Use of Requests for Proposals (RFPs)

Minnesota took a novel approach by sending out a request for proposals to community groups focused on designing appropriate outreach strategies for the local level. Administrators of MinnesotaCare considered the response a success – 28 public and private proposals were submitted and 26 approved. The applications were evaluated based on the strategies proposed, the ability to raise matching funds, and the capability to contact and serve the targeted population. MinnesotaCare plans to provide $1.5 million in grants over the biennium to support the initiatives of the selected groups.

2. Coordinated Outreach Efforts

An approach common to all nine states was the coordination of outreach efforts with other programs. Relying on an "extended family" in the community serves two primary functions: (1) it is a cost-effective method for programs with small outreach budgets; and (2) it effectively reaches shared target populations. Partners include schools, child care centers, local and state public health departments, providers, medical associations, family planning clinics, state maternal and child health departments, Medicaid, WIC, Head Start, Healthy Start, among other programs and organizations (See Table 16).

V. Coordination and Linkages of Services and Programs

To increase the capacity of children's health insurance programs, the nine states have developed strategies to coordinate services with other health programs in the state.These linkages involve efforts to coordinate enrollment, outreach, computer networks, administration, referral, the care of children with special health care needs, and efforts to provide continuous eligibility to children in families with fluctuating income.

This section addresses the following topics:

• referring eligibles to Medicaid; coordinating electronic and administrative structures between programs;
• referring individuals to Medicaid or other programs for inpatient care or other benefits not provided by separate state programs;
• coordinating with Medicaid eligibility status of children in families with fluctuating incomes;
• coordinating state programs for insured adults and children;
• utilizing the same provider network for various state programs;
• coordinating care for children with special health care needs with the State Maternal and Child Health Bureaus;
• establishing joint outreach efforts to identify potential enrollees; and
• coordinating efforts with other programs to enroll children in children's health insurance programs.

A. Referral to Medicaid When Applying to the Children's Health Insurance Program

Four of the nine states reported the establishment of a systematic referral for children eligible for Medicaid to the Medicaid program by separate children's health insurance programs.

• In Colorado, families are referred to the county social services office for Medicaid enrollment. If they are applying to the CCHP program by mail, they receive a letter explaining why they are ineligible for the CCHP, notified of their potential eligibility for Medicaid, and referred to Medicaid.
• In Massachusetts, applications for the state program are screened for Medicaid eligibility and eligibles are then sent Medicaid applications.
• In New York, the State Department of Social Services (DSS) coordinates with Child Health Plus to refer children between Medicaid and other children's programs. County DSS offices also refer children and families to Child Health Plus and provide guidance to families regarding Medicaid and Child Health Plus eligibility. In addition, DSS explains procedures for terminating Child Health Plus when Medicaid eligibility is established.
• In Pennsylvania, the five CHIP health plans are required to refer ineligible families to other sources of health care for which they may be eligible. Generally, families are referred to Medicaid programs. Last year over 8,000 referrals were made to the Pennsylvania Medicaid program.

B. Electronic/Administrative Coordination of Enrollees' Eligibility With Medicaid

Two of the states have integrated the administrative procedures and computer systems between their separate children's health insurance and Medicaid programs.

• The Florida Healthy Kids Corporation interfaces electronically with Medicaid's third party administrator to verify that enrollees are not currently enrolled in Medicaid. However, the Healthy Kids program does not check a child's eligibility for Medicaid, but only their enrollment status.
• In Minnesota, the same employees will process the applications for both Medicaid and future MinnesotaCare, beginning June 1, 2000. If a family mistakenly applies to either MinnesotaCare or the Medicaid program, they are referred to the correct program.

C. Referral to Medicaid or Other Programs for Inpatient Care or Other Benefits Not Provided by the Program

Some children's health insurance plans offer a more limited benefit package with the intent of keeping costs low and insuring as many children as possible. In these cases, plans may find it helpful to coordinate services with the state Medicaid program so that children who become severely ill and in need of comprehensive benefits (perhaps not offered by the separate children's health insurance program) have access to Medicaid.

• CaliforniaKids does not offer inpatient care so they established a coordinated effort between CaliforniaKids and the Medicaid agency (MediCal) for inpatient care. Although the relationship is not formal, coordination with Medicaid is conducted on a case-by-case basis. When a child requires inpatient care, CaliforniaKids contacts and coordinates with MediCal to assist families in obtaining necessary services. However, CaliforniaKids has needed to coordinate the care of children with MediCal in only seven cases since the establishment of the program.
• In Pennsylvania, Caring Programs provide coverage to "wrap-around" the CHIP program. [The Children's Health Insurance Program provides coverage to children up to age 16 whose families are below 185% of the poverty level. These children receive free coverage. Children under age 6 up to 235% of the poverty level are eligible for subsidized coverage. Applicants must be residents of Pennsylvania for at least 30 days (except newborns) and cannot have access to any other private insurance or the Medicaid program.] The Caring Programs subsidize coverage for children ages 6-18 between 185-235% of poverty and offer free coverage for 17- and 18-year-olds under 185% FPL who are too old to be eligible for the CHIP program. In addition, Blue Cross/Blue Shield allows families on the CHIP waiting list to "buy-in" to the program while they wait for an open spot. The Caring Foundation will often subsidize their coverage until a spot in CHIP is available.

D. Coordination with Medicaid as Families' Income Changes

The actual income of low-income families tends to fluctuate a great deal, causing children's eligibility for various state programs to change from year to year. In an effort to provide continuity of care for this population, three of the six states with stand-alone programs examined in this study have instituted protocols for referring children between Medicaid and separate children's health insurance programs.

• In Colorado, the new Colorado Basic Health Plan (to be established in July 1998) will assign the same enrollee number to their enrollees as was assigned to them by the Medicaid program. Therefore, both agencies will have a list of recipients with identical identification numbers. The goal is to create a seamless system and to prevent children from "falling out" of that system.
• In Massachusetts, there is two-way communication regarding applications and denial of eligibility between the Children’s Medical Security Plan (CMSP) and Medicaid. If a child applies to CMSP, but is eligible for Mass Health (Medicaid), the child is enrolled in CMSP under presumptive eligibility and given an application to apply for Medicaid. The Medicaid office is informed of the enrollees eligibility for Mass Health so that they might be included in any outreach and enrollment efforts. This has been the established protocol as the CMSP application is much easier to complete than the Mass Health application, thus reducing the period of uninsurance of children waiting for enrollment in Mass Health. In addition, children denied eligibility for Mass Health are referred to CMSP.
• In New York, the State Department of Social Services (DSS) coordinates with Child Health Plus on referrals between Medicaid and other children's programs. County DSS offices refer children and families to Child Health Plus. In addition, DSS provides guidance regarding assessment of Medicaid and/or Child Health Plus eligibility and procedures for terminating Child Health Plus when Medicaid eligibility is established.

E. Coordination of Adult and Child Services

Washington State has worked to integrate its program for uninsured adults and children as much as possible in order to provide a simple method for families to obtain insurance. The state-supported program for adults, the Basic Health Plan, provides insurance coverage to adults up to 200% of poverty. This program enrolled children and adults until the advent of the Basic Health Plus program, a Medicaid expansion for children up to 200% of poverty. In order to prevent confusion within families qualifying for assistance, income eligibility was set at the same level for both programs. To simplify the effort further, there is a single enrollment form for both programs. In addition, there has been a tremendous effort focused upon synchronizing provider networks between the two programs. This year marked a significant event, when the two agencies administering the two programs sent out a joint RFP soliciting health plans to contract with the programs. There have also been consistent efforts to integrate the programs' computer systems.

F. Coordination of Provider Network With Other Children's Programs

In order to maintain and increase the continuity of care, state children's health insurance programs may coordinate with other state programs to develop a common provider network.

• CaliforniaKids contracts with the same providers as several other state programs: Assistance for Infants and Mothers (AIM), MediCal, and the Child Health, Disability and Prevention Program (CHDP).
• In Florida, the Healthy Kids program has included county public health clinics as providers in an effort to allow children to continue to obtain care from their historical providers.
• MinnesotaCare originally used the same providers as the FFS Medicaid program. In 1996, all MinnesotaCare recipients were enrolled in health plans and health plan providers that participate with a Medicaid program, as also required, participate in MinnesotaCare.

G. Coordination of Care for Children With Special Health Care Needs With the Maternal and Child Health Bureau

Three of the nine states reported comprehensive efforts to coordinate the care of children with special health care needs with the state health departments’ Maternal and Child Health (MCH) programs. Since state Maternal and Child Health programs have traditionally been responsible for the care of special needs children, there has been concern about the enrollment of these children into programs that may contract with managed care plans. To ensure access to comprehensive care, the state MCH programs have interacted with families and managed care plans to provide "wrap around" services, coordinate care, and provide transportation. MCH programs have also focused on continuing the provision of other services not generally covered by managed care but provided through Title V programs. For example, children who become severely ill may require services covered under the MCH program for children with chronic illnesses. Therefore, MCH may coordinate with the separate state program to ensure such children receive the appropriate care. In two instances, Healthy Kids has utilized the Maternal and Child Health program as a reinsurer for children with chronic conditions not covered by Healthy Kids.

• In Tennessee, ninety percent of children with special health care needs are enrolled in TennCare. There are currently eleven managed care organizations participating in TennCare. Therefore, the Maternal and Child Health program has focused a substantial amount of effort on negotiating the appropriate care for children with special needs with the contracted plans. In cases where children are denied services, families of those children appeal to the health plan, and if denied again, the Maternal and Child Health program will often provide the services through the Children’s Special Services (CSS) program. This most often occurs with the provision of medical devices.
• In Washington, the State is beginning to enroll SSI-eligible children in managed care through the Basic Health Plus program. There is a substantial amount of coordination occurring between the Children with Special Needs Department and Medicaid as they seek to determine the best way to provide care for this population.

H. Coordination With Other Programs to Enroll Children in the Children's Health Insurance Programs

Seven of the nine states reported coordination between their children's health insurance program and other state programs with respect to enrolling children.

• Other state programs in California have enrollment information for the CaliforniaKids program and can assist families in filling out the application.
• In Colorado, children enrolled in the free meal program, Health Care Program (HCP), WIC, the state prenatal program, or either of the two food programs, can automatically enroll in CCHP if they are not enrolled in Medicaid. If children enter the CCHP program through any of these programs, CCHP requires the "enrolling program" to verify assets. A shorter application form was developed for this purpose, and is available through each of the aforementioned programs and schools.
• In Massachusetts, WIC clinics and activity centers have on-site registration into the Children's Medical Security Plan (CMSP). In addition, any health or human services agency can assist in the enrollment of applicants to CMSP. Individuals in each department have been trained to assist with mail-in or phone-assisted enrollment for the CMSP or Mass Health (Medicaid) programs. Providers at community health clinics and outpatient clinics, school nurses and advocates have also been trained to enroll children into the program. Assisting this effort is a 45-day presumptive eligibility provision for the Children's Medical Security Plan allowing providers to fax an application to CMSP and treat children immediately.
• Minnesota has developed a common enrollment form for MinnesotaCare and the state Medicaid program. This will assist with the enrollment process while reducing administrative efforts.
• TennCare distributes applications at county health department offices, permitting families to enroll on site. The process requires approximately fifteen minutes, and applicant are interviewed face-to-face to ensure their understanding of the forms and the way in which TennCare operates. In addition, families may examine the provider networks for each plan before they make any choices. Health department staff are also trained to assist families through grievance and appeals processes if a claim is denied. Since working with local health departments, community acceptance of TennCare has increased dramatically in Tennessee.
• In Washington, the Health Care Authority (which administers the Basic Health Plan for adults) coordinates with the Department of Social and Health Services (which administers Basic Health Plus for children) to provide a uniform application for parents and children applying to the two programs. In order to reduce confusion, children and parents may enroll into the two separate programs with the same application form. The Department of Social and Health Services is responsible for verifying eligibility for applicants to both programs. The Department of Social and Health Services then enrolls the children, then forwards the list of eligible adults to the Health Care Authority for enrollment.

Table 17: Summary of Linkages Between Children's Health Insurance Programs and Other State Programs

	CaliforniaKids	Colorado Children's Basic Health Plan	Florida Healthy Kids	MA Children's Medical Security Plan	MinnesotaCare	New York Child Health Plus	Pennsylvania CHIP	TennCare	Washington Basic Health Plus
Referral to Medicaid on Application		x		x	x	x	x
Electronic/Administrative Coordination of Eligibility with Medicaid			x		x
Referral to Medicaid/Other Program for Benefits Not Covered by CHI Program	x				x		x
Coordination with Medicaid as Families' Income Changes		x		x	x	x
Coordination of Adult and Child Services									x
Coordination of Provider Network with Other Children's Programs	x		x		x
Coordination of Care for Children with Special Health Care Needs			x					x	x
Coordination for Outreach and Marketing	x		x	x	x				x
Coordination of Enrollment Efforts	x	x		x	x	x		x	x

Appendixes

Appendix A: Overview of Review for This Resource Book

California Kids

HISTORY:

CaliforniaKids is a non-profit organization sponsored by private donations that was founded July 30, 1992. The program was initially based in Los Angeles, and has since expanded to 33 other counties. CaliforniaKids offers children a limited health insurance product that focuses on preventive and primary health care. The program coordinates with MediCal, the state Medicaid program, to obtain care for children who need inpatient treatment or other serious care that CaliforniaKids does not provide. CaliforniaKids partners with community organizations to identify and enroll eligible children. Children enrolled in CaliforniaKids pay no monthly premiums, but are responsible for small copayments for their care. CaliforniaKids has provided coverage for 18,000 children since its inception in 1992.

TARGET POPULATION:

Uninsured children ages 2-18 who are unmarried, ineligible for coverage under any federal or state health benefit program, not currently enrolled under a private health care contract, and enrolled and attending school (if school-age) are eligible for CaliforniaKids if their family income is below 200% of the poverty level. In August 1997, a pilot program was begun in San Diego that will expand the income eligibility level up to 300% of the poverty level in that county.

BENEFIT PACKAGE:

Benefits covered by CaliforniaKids include health screenings, immunizations, behavioral health care, 24-hour nurse access hotline, and hearing screening without co-payment, emergency treatment with a $25 co-payment, outpatient care and doctor visits with a $5 co-payment each, and prescriptions, dental care and eye glasses with a $10 co-payment each.

PROVIDER NETWORKS AND REIMBURSEMENTS:

CaliforniaKids utilizes a managed care, capitated system to maintain cost-effectiveness, minimize risk and unnecessary administrative expense due to excessive claims processing, and provide a "medical home" for the child. The network maintains choice and is sensitive to access, culture, language, gender, and age of child. Over 15,000 health care providers are contracted to provide services throughout the State and a 24-hour nurse hotline is available to all members to provide health care information and re-direct care from the emergency room to a lower cost, appropriate alternative. Plans donate their direct administrative expenses. CaliforniaKids partners with medical groups and IPAs, which offer wellness education to its members. Services are administered by Blue Cross of California, Delta Dental, Vision Service Plan, Wellpoint Pharmacy, and Health Affairs International and Access Health.

FINANCING:

CaliforniaKids is financed through private donations. CaliforniaKids does not collect premiums, but charges nominal copayments for care. Costs are kept low by offering a limited benefit package and minimizing administrative costs.

Colorado Children's Health Plan

HISTORY:

The Colorado Children’s Health Plan (CCHP) was established in 1992 as a community-based health care reimbursement program for low-income children. CCHP operates as a health maintenance organization that is administered by the University of Colorado Health Sciences Center. The program initially targeted rural counties with a low number of safety net providers, and built its own network of physicians. Recent legislation established the Children’s Basic Health Plan (CBHP), a program which will expand eligibility under CCHP up to age 18 and extend the network into every county in the state. CBHP will be a full benefit program administered by private HMOs. The CBHP will be funded in part by the Title XXI block grant.

TARGET POPULATION:

The target population of CCHP is children age twelve and under with incomes up to 185% of the poverty level who are not eligible for Medicaid. Under CBHP, the target population will expand to include children up to age eighteen. Enrollment in FY1996 was 4,893 children. In FY1997 the target is 6,217 children, and in FY1998 the target is 12,041 children.

BENEFIT PACKAGE:

The benefit package was modeled after the Blue Cross/Blue Shield Caring Programs. Benefits include most preventive services, but do not include inpatient hospital care, eyeglasses, hearing aids or dental care. There is a maximum annual benefit of $10,000 per child. The program expansion will include inpatient and mental health care.

PROVIDER NETWORK AND REIMBURSEMENT:

CCHP is administered by the state of Colorado through the University of Colorado Health Sciences Center. The program has a statewide network of pediatric physicians. Primary care physicians are reimbursed on a capitated basis and bear risk. Medical specialists are reimbursed on a fee-for-service basis.

FINANCING:

Funding is obtained for CCHP through a combination of state appropriations and private donations. Funding comes from several sources: General Fund; public funds consisting of a portion of the Medicaid teaching adjustment paid to University Hospital; cash reserves and interest paid on those reserves; private donations; and enrollment fees. The enrollment fee is a $25 per child yearly payment in lieu of premium contributions. Copayments are required on doctor visits, health screenings, and prescriptions. Blue Cross/Blue Shield HMO donates all claims processing services.

Florida Healthy Kids Corporation

HISTORY:

The Florida Healthy Kids Corporation was established in November 1990 to create a comprehensive insurance product for school children using Florida school districts as a grouping mechanism. A HCFA(now known as CMS)-funded demonstration project of Healthy Kids was initiated in Volusia County in 1992 and was completed in 1995. In late 1993, Healthy Kids began expanding into additional counties utilizing both state and local government funds. Healthy Kids currently serves 19 of Florida’s 67 counties, which contain approximately half the state’s uninsured children. The program is designed to provide affordable access to health insurance for all Florida children. Children who are not on the school lunch program pay the entire cost of their insurance, while children who are on the school lunch program have access to subsidized insurance. Participation by Florida counties in the Healthy Kids program is strictly voluntary.

TARGET POPULATION:

Once a school district elects to participate in the program, qualified children become eligible for Healthy Kids. Children must be between the ages of 5 and 19, uninsured (i.e. not enrolled in Medicaid or private insurance), and enrolled in school up to the 12th grade. Counties may expand eligibility to allow children of other age groups the ability to participate (e.g. children who are less than school age whose families are enrolled in Healthy Kids).

BENEFIT PACKAGE:

Program benefits are extensive, including inpatient care, surgery, emergency services and transportation, eyeglasses, hearing aids, physical therapy, mental health services, pre-natal care and delivery, and organ transplants. Copayments are required for certain benefits. Counties may add additional services such as dental care to the package. Healthy Kids has a $1,000,000 lifetime cap on services received.

PROVIDER NETWORK AND REIMBURSEMENT:

Eight managed care networks serve Healthy Kids enrollees. Insurers are selected on the basis of five variables: price, benefits, provider network, reporting capabilities, and general criteria such as accreditation and solvency. Healthy Kids aggregates state, local and family funds to pay premiums to commercial health plans that assume the insurance risk.

FINANCING:

All individuals enrolled in the Healthy Kids program are required to pay some portion of the cost of their insurance. Sliding-scale premiums are based on reported family income required for participation in the school lunch program. The three cost-sharing levels are "Free Lunch", "Reduced Lunch", and "Not on Lunch Program". Premium levels vary by county. Funding for the demonstration project in Volusia county came from a HCFA(now known as CMS) waiver. All subsequent funding has been granted through a combination of state, local and family contributions.

Children’s Medical Security Plan of Massachusetts

HISTORY:

Authorizing legislation for the Children’s Medical Security Plan (CMSP) was passed in 1993 to provide access to preventive and primary care services for Massachusetts' uninsured children. The plan originally covered uninsured children age 12 or younger. The impetus for the program was initially the national attention to health care reform and access to health care for all individuals. The passage of the Health Access Law in July 1996 expanded CMSP program eligibility to include adolescents up to age 18. In 1997 administration of the plan was transferred to the state Department of Public Health.

TARGET POPULATION:

The target population for CMSP is uninsured children under the age of 19 who are residents of Massachusetts and who are not eligible for Medicaid. The number of projected children eligible for CMSP is 76,000.

BENEFIT PACKAGE:

The Children's Medical Security Plan offers a range of benefits designed to cover the services most frequently used by children. Routine well-child check-ups, immunizations, and smoking prevention services are covered without co-payment. All other covered benefits require a co-payment of are $1, $3 or $5 based on family income guidelines. Limited coverage is offered for emergency care, prescription drugs, durable medical equipment, and outpatient mental health services. CMSP does not pay for OTC drugs, ambulance transport, inpatient care, dental care, or early intervention. However, children enrolled in CMSP may be eligible to receive inpatient care in any of the state hospitals or community health clinics through the state free care pool.

PROVIDER NETWORK AND REIMBURSEMENT:

The Community Health Plan (CHP) and John Hancock administer the health insurance program. The Community Health Plan serves three rural counties with approximately 3,000 participants. John Hancock serves the remainder of the state, with roughly 34,000 enrollees. John Hancock reimburses its providers on a fee-for-service basis, while CHP reimburses both through capitation and fee-for-service arrangements.

FINANCING

There are three sources of funding for the program: tobacco taxes, general funds, and family premium contributions. Families earning 200% or less of the federal poverty level receive the insurance free of charge. Those families earning below 400% of the poverty level are charged a reduced premium rate of $10.50 per child per month, with a $32.50 maximum per family per month. Families with income over 400% of poverty are charged the full premium, which is currently set at $52.50 per month.

Minnesotacareminnesotacare

HISTORY:

MinnesotaCare began in 1993 as part of a package of legislation aimed at reducing the number of uninsured in the state of Minnesota. With the advent of the MinnesotaCare demonstration project, all MinnesotaCare enrollees were transitioned to mandatory managed care. Phase I of the demonstration extended Medicaid coverage to families with children under 275% FPL with no insurance coverage. Under the demonstration, children and pregnant women receive all benefits available to traditional Medicaid enrollees. In May 1997, a bill was approved to expand MinnesotaCare eligibility to adults without children with income from 135% FPL to 175% FPL. The legislation also reduced provider taxes and added nonpreventive dental coverage for adults in families below 175% FPL.

TARGET POPULATION:

MinnesotaCare is available to families with children who have income of less than 275% FPL, and individuals who have incomes of less than 175% FPL. To become eligible for MinnesotaCare, one must have been uninsured for at least four months or have had no access to employer-subsidized coverage for 18 months or more. An asset test will be implemented when the amended demonstration waiver is approved by HCFA(now known as CMS). Under the asset test, families cannot have more than $30,000 in assets, and individuals cannot have more than $15,000 in assets to be eligible for the plan.

BENEFIT PACKAGE:

The program offers a comprehensive benefit package including inpatient hospital benefits. However, inpatient benefits are capped at $10,000 annually for adults without children and for parents with incomes greater than 175% FPL.

PROVIDER NETWORK AND REIMBURSEMENT:

Enrollees have the opportunity to choose a health plan upon enrollment into the program. Provider reimbursement was originally structured on a fee-for-service basis but now is a capitated payment system.

FINANCING:

MinnesotaCare was originally funded through a cigarette tax, a provider tax, and family contributions. The cigarette tax is no longer used for MinnesotaCare support; it was only applied from July 1992 through January 1994. In July 1995, the state 1115 demonstration waiver was implemented, and the federal match was added to the funding mix. In 1997 a reduction was made in the provider taxes due to a surplus in MinnesotaCare funds.

New York Child Health Plus

HISTORY:

The Child Health Plus program was passed by the New York State legislature in 1990, and by August of 1991, children began receiving coverage under the program. New York’s Child Health Plus is the largest of 13 non-Medicaid, taxpayer-funded child health insurance programs in the country. As of July 1, 1997, the program was providing coverage to over 135,000 children. The program has estimated target enrollment over the next few years to total 250,000; this number may increase significantly due to recent federal legislation. The overall intent of the Child Health Plus Program is the following:

• To improve the health status of children participating in the program by providing a "medical home"
• To provide primary, preventive, outpatient and inpatient health insurance coverage to low income children by removing financial barriers to purchasing such coverage through an individual subsidy program
• To increase children’s access to primary comprehensive, preventive and inpatient health care services
• To reduce and more effectively target bad debt and charity care expenditures in the state of NewYork

TARGET POPULATION:

Children considered eligible for the program must be either uninsured or underinsured, residents of NewYork State, under the age of 19, and not eligible for state Medicaid benefits. Children under age 19 in families with an income below 222% FPL are eligible for an income-variable premium subsidy. Children in families above 222% FPL are permitted to buy into the program without any premium subsidy.

BENEFIT PACKAGE:

The program began providing coverage to children in August of 1991, initially providing subsidized primary and preventive outpatient care to children under age 13. In 1997, the program extended benefits to include inpatient care (excluding inpatient services for mental health and substance abuse) and extended coverage to include children through age 18.

PROVIDER NETWORK AND REIMBURSEMENT:

The provider network currently consists of 15 insurance plans contracted to provide health services to enrollees, of which 11 are MCOs and 4 are traditional indemnity plans. As of October 1, 1997, 24 insurance plans, with almost all providing a managed care product, will participate in Child Health Plus. Additionally, a marketing and outreach organization has been contracted to promote the plan throughout the state. This will be complemented by an in-house statewide marketing effort.

FINANCING:

The program is financed through a provider surcharge established under the New York Health Care Reform Act of 1996. The premium contribution from families participating in the program is an additional funding source.

Pennsylvania Children's Health Insurance Program

HISTORY:

A 1992 Penn State University study on uninsured children in Pennsylvania precipitated the interest in creating a state-subsidized health insurance program for children. The Pennsylvania Children’s Health Insurance Program was enacted in November 1992 and implementation began in May 1993. The state-sponsored program was initially designed to cover 29,000 uninsured children ages 1-6 whose families were below 100% of the poverty level. In May 1994 the program was expanded to cover children ages 1-13 up to 185% of the poverty level due to excess funds. The Children's Health Insurance Program is currently capped at 53,879 children. There are approximately 3,000 children on the waiting list.

TARGET POPULATION:

The target population of the Children's Health Insurance Program is children up to age 16 whose families are below 185% of the poverty level. These children receive free coverage. Children under age 6 up to 235% of the poverty level are eligible for subsidized coverage. Applicants must be residents of Pennsylvania for at least 30 days (except newborns) and cannot have access to any other private insurance or the Medicaid program.

BENEFIT PACKAGE:

The focus of the Children's Health Insurance Program is on preventive and primary care services. Primary care, vision and hearing screening, emergency care, outpatient care, mental health treatment and dental care are provided through the benefit package. Inpatient care is covered through the program with a limit of 90 days in-hospitalization.

PROVIDER NETWORK AND REIMBURSEMENT:

The Department of Insurance Office of Special Projects contacts with five HMOs, and each plan insures a different region of the state. Plans are selected through a competitive bidding process. Three of the HMOs are Caring Foundations set up by Pennsylvania Blue Cross/Blue Shield. The State Department of Health approves provider networks, and children have their choice of providers from within the plan.

FINANCING:

The Pennsylvania Children’s Health Insurance Program is supported by a $0.02/pack state cigarette tax, which generates approximately $21.5 million annually. In the 1996 session, the program asked the state legislature to appropriate another $0.01 of the cigarette tax to the program. The cigarette tax fell through, but the legislature appropriated an additional $10 million in general funds to the program.

Tenncare

HISTORY:

TennCare is a Medicaid 1115 Waiver program that began January 1, 1994. On that date, about 700,000 Tennesseans who had been enrolled in Medicaid were shifted into one of twelve managed care organizations throughout the state. Also on that date, the state began offering TennCare coverage to the estimated 750,000 uninsured Tennesseans, regardless of income or employment status. Tennessee residents were eligible for TennCare under the uninsured category if they did not have insurance on March 1, 1993. TennCare’s scope is broader than virtually any other state’s 1115 waiver demonstration project. A sliding scale is used to determine premiums and patient cost-sharing for enrollees above 100% of poverty. Persons within 100-200% of the FPL have increased co-payments up to 10% of the total cost of treatment. Categorical and asset test restrictions were removed from Medicaid eligibility with the onset of TennCare. On January 1, 1995, the state closed enrollment for the uninsured population, but remained open to those who are uninsurable. However, on April 1, 1997, enrollment into TennCare was opened up to all children under age 18. There is no intention of closing enrollment to children at any time in the future.

TARGET POPULATION:

Enrollment in TennCare is currently open to persons eligible for Medicaid, the "uninsurable" population, displaced workers, and all children under age 18 who do not have access to insurance. Children under eighteen are eligible for benefits on the day of their enrollment.

BENEFIT PACKAGE:

Program benefits are very comprehensive, and include inpatient hospital care, hospice care, dental services, home health care, durable medical equipment, medical supplies, ambulance transportation, transportation, rehabilitation, chiropractic services, private duty nursing, speech therapy, sitter services, convalescent care, and organ transplants.

PROVIDER NETWORK AND REIMBURSEMENT:

To implement TennCare, the state was divided into twelve Community Service Agencies through which each contracting managed care organization operates and guarantees access to services through provider networks. TennCare determined the terms and conditions of its managed care plan and invited plans to participate. Plans that could prove that they could provide the services were granted contracts with TennCare. Initially twelve MCOs contracted with TennCare. For the first three years, Tennessee allowed the plans to operate as PPOs. By January 1, 1997, they had to be converted to HMOs. Currently there are ten MCOs servicing the TennCare population.

FINANCING:

TennCare was financed by pooling federal, state and local expenditures for indigent health care, including $2.2 billion of federal dollars. Pooled resources total $3.455 billion, of which $2.245 billion is used to fund the current year of the TennCare program. The remainder is used to fund long-term care programs, Home and Community Based Services Waiver programs, Medicare crossovers through the Medicaid system, Medicare premiums, and administration for the total program. No new taxes were established to pay for TennCare.

Washington Basic Health Plus

HISTORY:

In 1993, Washington State created the Basic Health Plus program for children under 200% of the federal poverty level through a Medicaid expansion. These children were previously eligible for health insurance through the full state-subsidized Basic Health Plan established in 1988, under which adults below 200% of the federal poverty level still receive coverage. The Basic Health Plus program was established to take advantage of the federal funding available through Medicaid. Children covered under the program receive a comprehensive benefit package at no cost to their family. Provider networks are aligned between the Basic Health Plus program and the Basic Health Plan so that families can visit the same physicians.

TARGET POPULATION:

Children ages 0-19 whose families earn less than 200% of the poverty level are the target population of Basic Health Plus.

BENEFIT PACKAGE:

The Washington Basic Health Plus program has the same rich benefit package traditionally provided under the state Medicaid program. This includes all preventive services, plus benefits such as inpatient care, dental care, eyeglasses and hearing aids. Basic Health Plus provides routine screenings of up to $125 per child per calendar year without co-payment (this does not apply to well-baby care). Immunizations and well-child visit are covered up to a maximum of $400 per calendar year for children ages 1-4. Children receive a 50% discount on glasses and a 25% discount on contact lenses. There is an unlimited inpatient stay, but care must be authorized within 48 hours of admission.

PROVIDER NETWORK AND REIMBURSEMENT:

There are currently fourteen managed care plans contracting with Basic Health Plus. There is almost a complete overlap between the provider network utilized by Basic Health Plus and that used by the Basic Health Plan.

FINANCING:

The program is funded through a combination of state and federal funds through the Medicaid match. State funds are obtained primarily through state taxes on cigarettes and alcohol.

Appendix B: State Program Contacts

CONTACTS

California
Michael Koch, Executive Director
California Kids Healthcare Foundation
16830 Ventura Blvd.
Suite 342
Encino, CA 91436
818-461-1404

Colorado
Bonnie Sherman, Director
Colorado Child Health Plan
5250 Leetsdale, #105
Denver, CO 80222
303-372-2160 ext. 22149

Florida
Rose Naff, Director
Florida Healthy Kids Corporation
223 S. Gadsden St.
Tallahassee, FL 32301
904-224-5437

Massachusetts
Clare Reilly, Director
Maternal & Child Health Access Unit
MA Children’s Medical Security Plan
Department of Public Health
250 Washington St., 5^th floor
Boston, MA 02108-4619
617-624-5008

Minnesota
Kathleen Henry, Director
Health Care for Families and Children
444 Lafayette Road
St. Paul, MN 55155-3829
612-296-8818

New York
Judith Arnold, Deputy C
Department of Health
Empire State Plaza
Corning Tower
Room 1495
Albany, NY 12237
518-473-7883

Pennsylvania
Lowware Murray, Project Manager
Children’s Health Insurance Program
PA Department of Insurance
1326 Strawberry Square
Harrisburg, PA 17120
717-783-0213

Tennessee
Theresa Clark, Assistant Commissioner
TennCare
Dept. Of Finance of Administration
729 Church Street
Nashville, TN 37247-6581
615-741-0213

Washington
Linda Melton, Assistant Administrator
WA Basic Health Plan
Washington State Health Care Authority
P.O. Box 42683
637 Woodland Square Loop SE
Olympia, WA 98504-2683
360-923-2996

APPENDIX C: Resource Kits by State

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